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£ <br />□ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />city ' 77 <br />□ Consultation □ Change of Owner □ Repairs or Remodel <br />Facility Owner[^Billing Party JZTacility Contact □ Property Owner □ Contractor □ Architect <br />Prilling Party /0'Facility Owner p^acility Contact □ Property Owner □ Contractor □ Architect <br />City <br />Phone <br />□ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indica-First Name Last name <br />StateCityAddress <br />EmailPhonePhone <br />□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGERPROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />PEDate <br />Rev 06/12/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Application for <br />Operating Permit <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />ZIP <br />VIN <br />| <br />TA <br />Last name <br />ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws^—---------~ <br />APPLICANTS SIGNATURE: ---------- DATE: DH <5 / ---------- <br />City State <br />TWA CA <br />zH'Other <br />ty^eA^Oifi^rjumber <br />Type of Service <br />Requested <br />Comments <br />a <br />Email <br />/irst Name <br />Address <br />Phone Phone <br />New Facility <br />ite type and license number <br />Payment_ <br />MAR II g 2DX <br />acomrac5S°is^ <br />If contractor, indicate <br />Site Address^ . <br />^1 <br />APN <br />Facility Name <br />AT <br />Supervisor District <br />If contractor, indicate type and license number <br />State <br />CA. <br />License Plate Number <br />taep,edBv